A MULTI-CENTRE SURVEY ON BARRIERS AND FACILITATORS OF ADHERENCE TO DIETARY AND FLUID RESTRICTIONS AMONG ADULT CHRONIC KIDNEY DISEASE PATIENTS UNDERGOING HEMODIALYSIS IN CEBU

A total of 254,028 deaths, which is composed of 131,008 deaths in men, and 123,020 deaths in women were caused by chronic kidney disease. The estimated age-standardized death rate due to kidney diseases was at 15.6 per 100,000 population1. Further, more than 10% of the general population worldwide is affected by chronic kidney disease, which is estimated to be more than 800 million individuals. Chronic kidney disease represents an especially large burden in low- and middle-income countries, which are least equipped to deal with its consequences. It is one of non-communicable diseases that has emerged as one of the leading causes of mortality worldwide2. According to the National Kidney and Transplant Institute (NKTI), one Filipino develops chronic renal failure every hour or about 120 Filipinos per million population every year. Latest estimates show that around 2.3 million Filipinos have chronic kidney disease (CKD). In 2016, more than 36,000 patients were on dialysis treatment which reflects a 15 percent increase in the number of patients in just one year3.

In patients with chronic kidney disease, there is deterioration in kidney function that results in the kidney's inability to eliminate waste products, maintain acid base, fluid, and electrolyte balance4. Most of the patients are treated with hemodialysis (HD) three times per week in which a machine is used to clean the blood. Hemodialysis is a lifesaving therapy. But it makes enormous demands on patients with end-stage renal disease (ESRD), thereby affecting their quality of life5.

 In CKD patients undergoing hemodialysis, dietary restrictions are recommended to reduce accumulation of metabolic wastes and slow down risk for mortality and morbidity6. In order to prevent fluid overload, removal and control of excess fluid is the cornerstone of volume management in CKD patients7. Significant adaptions to their life, accepting dietary and fluid restrictions, rigorous medication regimens, and complex renal replacement therapy routines must be made by these patients8. Patients' adherence to dialytic procedures, medications, dietary and fluid restrictions is paramount in proper management of CKD population. Nonadherence to the prescribed diet and fluid restrictions is a severe health problem that limits the benefits of routine therapies. It can cause electrolyte imbalance, fluid overload, and exacerbation of symptoms, poor quality of life, repeated hospitalization, higher health care costs, and high mortality9.

Hence, this study will determine the barriers and facilitators of adherence to dietary and fluid prescription among adult patients with chronic kidney disease on hemodialysis. The study would contribute to understanding the perceived barriers and adherence behaviors among dialysis patients regarding fluid and dietary restrictions. The study results can be used by healthcare providers, policymakers, and advocacy groups to develop programs and initiative aimed at improving care and support for CKD patients undergoing hemodialysis. Ultimately, this study may contribute to the wider body of knowledge on the management of chronic kidney disease in the development of interventions and strategies to improve adherence and potentially improve clinical outcomes for these patients.

This study was a cross-sectional survey that collected and analyzed data to determine the barriers and facilitators of adherence among adult patients with chronic kidney disease undergoing hemodialysis from September 2025. The study was conducted at different dialysis centers within Metro Cebu, Philippines. This area included standalone dialysis centers that provide hemodialysis treatment to a diverse population of adult patients with Chronic Kidney Disease. The inclusion of multiple sites within Metro Cebu ensures a representative sample, reflecting a range of socioeconomic, cultural and healthcare access conditions. This study used a researcher-made survey form to gather information about the patient’s age, sex, civil status, educational attainment, employment status, history of smoking and drinking, and presence of comorbidities. This survey form was pilot tested on a group 12 individuals and Cronbach’s alpha was 0.712, a good sign for internal consistency of the items.  This survey form also included the barriers and adherence to dietary and fluid restrictions. The estimated sample size is 180, computed using Cochran’s formula for sample size computation, with the confidence level at 95%, allowable error is 5%, and the proportion of patients who are adherent and non-adherent to dietary requirements and fluid limitation is assumed to be 50%, and a fixed population size of 320. Participants were recruited using purposive sampling. Only institutions that provide written authorization through an equivalent institutional permission were included as participating sites. Descriptive statistics was used to summarize the demographic and clinical characteristics of the patients. Frequency and proportion were used for categorical variables, median and inter quartile range for non-normally distributed continuous variables, and mean and SD for normally distributed continuous variables note. Independent Sample T-test, Mann-Whitney U test and Fisher’s Exact/Chi-square test were used to determine the difference of mean, rank and frequency, respectively, between male and female patients. Shapiro-Wilk test was used to test the normality of the continuous variables. Missing values were neither be replaced nor estimated. All tests were two-tailed and p-value<.05 was considered significant. 

Table 1 presents the clinicodemographic characteristics of chronic kidney disease (CKD) patients categorized according to their adherence to fluid restrictions, subdivided into “very adherent” and “somewhat adherent” groups, with a total sample size of 179 patients. The mean age of the patients was comparable across the two adherence groups, with those very adherent having a mean age of 52.3 ± 13.7 years and those somewhat adherent 50.7 ± 15.3 years, with no statistically significant difference observed (p = 0.482).

Regarding sex distribution, a significant difference was noted between groups (p < 0.001). The very adherent group had a higher proportion of females (56.2%) compared to the somewhat adherent group, where males predominated at 70.7%. Civil status did not significantly differ between adherence groups (p = 0.252), with the majority being married in both groups (78.5% in very adherent and 70.7% in somewhat adherent). Educational attainment showed no statistically significant difference (p = 0.082), though more patients in the very adherent group attained college education (51.2%) compared to 50.0% in the somewhat adherent group.

Employment status was largely similar between groups (p = 0.590), with most patients unemployed (approximately 80% in each group). Lifestyle factors such as smoking (p = 0.507) and alcoholism (p = 0.612) showed no significant differences between groups. Comorbidities, including hypertension and diabetes mellitus, were highly prevalent but did not differ significantly between adherence groups. Specifically, hypertension was present in 72.7% of very adherent patients and 74.1% of somewhat adherent patients (p = 0.842), while diabetes mellitus was found in 49.6% of very adherent versus 41.4% of somewhat adherent patients (p = 0.303).

All patients in the study underwent hemodialysis thrice weekly. Overall, the data indicate that sex is the only clinicodemographic characteristic significantly associated with adherence to fluid restrictions among CKD patients, with females more likely to be very adherent. Other factors such as age, civil status, educational attainment, employment status, lifestyle habits, and comorbidities showed no significant association with fluid adherence in this cohort.

         The clinicodemographic characteristics of chronic kidney disease patients were analyzed according to their adherence to dietary requirements, dividing them into very adherent and somewhat adherent groups. The mean age differed significantly between the groups, with the very adherent patients being younger (48.2 ± 15.0 years) compared to the somewhat adherent group (54.0 ± 13.3 years), yielding a p-value of 0.008.

Sex distribution showed no statistically significant difference (p = 0.077), although a higher proportion of females was observed in the very adherent group (55.7%) compared to 42.2% in the somewhat adherent group. Civil status revealed a statistically significant association with dietary adherence (p = 0.027), where a larger percentage of married patients were somewhat adherent (81.7%) versus very adherent (67.1%), while the unmarried proportion was higher among the very adherent.

Educational attainment did not significantly differ between groups (p = 0.274). Vocational education was the most common level attained by both adherence groups, followed by high school and elementary education. Employment status was similar across groups (p = 0.665), with the majority unemployed in both groups.

Lifestyle factors such as smoking (p = 0.890) and alcoholism (p = 0.921) did not significantly influence dietary adherence. The prevalence of comorbidities such as hypertension and diabetes mellitus was also comparable between groups, with no statistically significant differences (p = 0.137 for DM). All patients underwent hemodialysis three times weekly.

Overall, younger age and civil status show significant associations with dietary adherence, with younger and unmarried patients more likely to be very adherent to dietary restrictions. Other clinicodemographic factors including sex, education, employment, lifestyle habits, and comorbidities did not demonstrate significant differences between dietary adherence groups.

The analysis of common barriers to adherence to dietary and fluid restrictions among chronic kidney disease patients identified three primary factors. Cravings were the most frequently reported barrier, affecting 44% of patients, indicating a strong desire or urge to consume restricted foods or fluids despite clinical recommendations. Weather factors were the second most common barrier, affecting 38% of patients, reflecting environmental conditions that may influence patients’ ability or willingness to adhere to restrictions. Financial constraints were reported by 18% of patients, highlighting economic limitations as a less common but still significant factor hindering compliance with prescribed dietary and fluid restrictions. These findings underscore the multifaceted challenges patients face in managing dietary and fluid adherence, suggesting the need for comprehensive support addressing behavioral, environmental, and socioeconomic dimensions.

         The facilitators of adherence identified in this study highlight several practical and psychological strategies employed by hemodialysis patients. Drinking cold water and sucking on ice cubes (reported by 28%) serve as effective means to manage thirst, a common challenge in fluid restriction, by providing oral cooling and reducing the sensation of dryness. Fear of experiencing previous unpleasant symptoms such as fluid overload or discomfort (22%) acts as a strong psychological motivator, reinforcing adherence through recognition of negative health consequences. Behavioral strategies like avoiding salty foods (20%), drinking water alongside medications (17%), and consuming small portions of meals throughout the day (13%) illustrate patients’ conscious efforts to control fluid and dietary intake in manageable ways.

Overall, these facilitators suggest that patients leverage both behavioral adaptations and psychological motivations to support adherence, aligning with literature emphasizing motivation, self-efficacy, and practical coping strategies as key drivers of treatment compliance. Encouraging such patient-initiated strategies in clinical practice can enhance adherence, improve symptom control, and ultimately contribute to better clinical outcomes in the hemodialysis population.

The study’s findings offer a comprehensive understanding of the multifaceted factors influencing adherence to fluid and dietary restrictions among chronic kidney disease (CKD) patients undergoing hemodialysis (HD). These insights not only highlight demographic associations but also illuminate both barriers and facilitators that shape patients’ adherence behaviors, underscoring the complexity of managing this vulnerable population.

Demographic Influences on Adherence

Sex differences emerged as a significant predictor of fluid adherence, with female patients more likely to comply with fluid restrictions than males. This finding corroborates prior evidence indicating gender disparities in health behaviors, where women often engage more actively in self-care practices (Karamanidou et al., 2018; Schmidt et al., 2016)10,11. Biological, psychological, and sociocultural factors may underlie this pattern, including greater health consciousness and adherence motivation in females. Conversely, males may benefit from targeted interventions addressing their unique psychosocial contexts and potential risk-taking tendencies to close this adherence gap.

Regarding dietary adherence, younger age and unmarried status were associated with better compliance. Older patients frequently face cognitive, functional, and social challenges that complicate adherence to complex dietary regimens (Szabo et al., 2017)12. The influence of marital status may reflect family dynamics—for married patients, shared meals and social eating behaviors can challenge dietary restrictions, while unmarried patients may experience more autonomy in food choices (Slomka & Metlay, 2010)13. These demographic findings stress the need for culturally sensitive, age-appropriate educational approaches and family-inclusive counseling to foster dietary adherence.

Barriers to Adherence

The study’s identification of cravings, weather-related factors, and financial constraints as top barriers aligns well with existing literature. Cravings are a universally reported challenge in restrictive diets, often driven by physiological hunger signals and psychological stress (Knafl & Grey, 2015)14. Behavioral interventions such as cognitive-behavioral therapy or motivational interviewing can help patients develop coping skills to resist cravings (Crist & Weiner, 2017)15.

Weather-related factors as barriers are less commonly documented but intuitively important. Extreme heat may exacerbate thirst, aggravating fluid management difficulties, while adverse weather can impact accessibility to care or food supplies (Keller et al., 2012)16. Recognizing such environmental influences calls for adaptive patient education and support, including guidance on managing thirst during hot weather, and ensuring continuity of care despite environmental challenges.

Financial limitations, although reported less frequently, remain a critical factor. Economic hardship restricts access to recommended foods and dialysis-related supplies, contributing to nonadherence and poorer outcomes (Flythe et al., 2019)17. Addressing this through social support services, subsidy programs, or community resources is essential in comprehensive care.

Facilitators of Adherence

The novel addition of facilitators in this study deepens the understanding of patient-centered strategies that promote adherence. The use of cold water and ice cubes by 28% of patients is a practical behavior supported by clinical guidance to alleviate thirst while limiting fluid intake (Mailani et al., 2021)18. This simple intervention can be emphasized in patient education as a manageable, non-pharmacological technique.

Fear of previous unpleasant symptoms motivated 22% of patients, highlighting the importance of experiential learning and symptom recognition in adherence. Patients who associate adherence with avoidance of distressing symptoms such as fluid overload or dyspnea may demonstrate higher compliance due to increased perceived severity and susceptibility (Welch, 2001)19. Clinicians should leverage this by reinforcing the causal link between adherence and symptom prevention during counseling.

Avoidance of salty foods (20%), drinking water with medications (17%), and eating small, frequent meals (13%) reflect intentional behaviors to adhere within daily life constraints. These strategies align with established recommendations to control sodium intake, manage fluid load concomitant with medication schedules, and moderate nutrient intake to avoid metabolic imbalances (Clark-Cutaia et al., 2014; Sulistyaningsih et al., 2020)20,21. Encouraging such adaptive behaviors can help patients feel empowered and supported in adherence.

In conclusion, this study demonstrates that adherence to fluid and dietary restrictions among chronic kidney disease patients on maintenance hemodialysis is influenced by key demographic factors such as sex, age, and civil status. Female patients showed higher fluid adherence, while younger and unmarried individuals demonstrated better compliance with dietary recommendations. The study also identified significant barriers to adherence, including cravings, weather-related challenges, and financial limitations, alongside facilitators such as drinking cold water or sucking ice cubes, fear of symptom recurrence, avoiding salty foods, timing water intake with medications, and consuming small, frequent meals.

These findings underscore the complex and multifactorial nature of adherence in the hemodialysis population, emphasizing the necessity for personalized, patient-centered approaches. Interventions must incorporate gender-specific support, age-appropriate counseling, family involvement, behavioral strategies to manage cravings, practical guidance to cope with environmental factors, and socioeconomic assistance to address financial barriers. Importantly, promoting and reinforcing patient-driven facilitators through education and empowerment can enhance self-efficacy and sustainable adherence.

Optimizing adherence in HD patients is critical to minimizing complications, improving quality of life, and enhancing clinical outcomes. Therefore, multidisciplinary care teams should integrate these insights into routine practice to tailor interventions according to individual patient needs, ultimately supporting better treatment adherence and health outcomes in this vulnerable population.